Behavior modification

Alpha-conditioning, applied behavioral analysis, applied behavioral therapy, assertiveness training, aversion therapy, basic learning techniques, biofeedback, CBT, classical conditioning, cognitive therapy, cognitive-behavior therapy, creative art therapy, dialectical behavior therapy, exposure therapy, flooding, hypnosis, implosion therapy, instrumental conditioning, instrumental learning, Ivan Pavlov, law of effect, operant conditioning, Pavlovian conditioning, psychoeducation, punishment, reinforcement, respondent conditioning, systematic desensitization.

Behavior modification includes the use of basic learning techniques, such as positive reinforcement, to alter human behavior. Positive reinforcement occurs when a behavior is followed by a pleasant incentive or reward that increases the frequency of performing that particular behavior.

Behavior modification is used today as an important part of changing health-related behavior, such as quitting smoking or learning to follow instructions for insulin medication. Another example might be a person who suffered from a heart attack and needs to increase their exercise level while avoiding high fat and high cholesterol foods.

The different behavioral therapies may have their origins in one of two psychological learning processes: classical or operant conditioning. Classical conditioning (sometimes called Pavlovian conditioning, respondent conditioning, or alpha-conditioning) focuses on reflexive (reactive) behavior or involuntary (instinctive) behavior. Any reflex can be conditioned to respond to a formerly neutral stimulus (anything that provokes behavior). Conditioned stimuli are associated psychologically with emotions or feelings such as anticipation, satisfaction (both immediate and prolonged), and fear. In classical conditioning, when the unconditioned stimulus is repeatedly or strongly paired with a neutral stimulus, the neutral stimulus becomes a conditioned stimulus and elicits a conditioned response. For instance, a person may set an alarm to go off at the times that they need to take insulin. Eventually, the alarm will no longer be necessary, and the person will remember to watch a clock for the times that insulin needs to be taken.

In human psychology, implications for therapies and treatments using classical conditioning differ from operant conditioning. Therapies associated with classical conditioning are aversion therapy, flooding, systematic desensitization, and implosion therapy. Classical conditioning is short-term, usually requiring less time with therapists and less effort from patients, which is unlike more introspective therapies that explore emotions and motivations. Classical conditioning is based on a repetitive behavior system and does not require personal introspection. Repetitive behavior is an action which is performed over and over again.

Operant conditioning is the modification of behavior brought about over time by having consequences for a certain behavior. Sometimes called instrumental conditioning or instrumental learning, it was first extensively studied by Edward L. Thorndike. In his law of effect, Thorndike theorized that some consequences strengthened behavior and some consequences weakened behavior. B.F. Skinner built upon Thorndike's ideas to construct a more detailed theory of operant conditioning based on reinforcement and punishment.

Reinforcement and punishment, the core ideas of operant conditioning, are either positive (adding a stimulus to an organism's environment) or negative (removing a stimulus from an organism's environment). For instance, positive reinforcement would be giving a child a toy after cleaning their room or buying one's self flowers after a week of properly following directions for taking insulin. Negative conditioning is generally not recommended by experts to change any behavior in adults or children, regardless of the circumstances, because many of the techniques are considered ineffective or possibly abusive. In most cases, negative conditioning is considered unethical.

Behavior modification has been used by psychotherapists, parents, and caretakers of the disabled. It uses basic methods to alter human behavior, such as reward and punishment, aversion therapy, reinforcement, and biofeedback. It is also used in school and health-related settings.

Analysis of the patients' thoughts is not required, but many non-behaviorists feel the therapy can be powerfully improved with cognitive analysis.

A major focus of behavior modification is giving compliments, approval, encouragement, and affirmation, which render the changed behavior a positive experience. Many experts believe that patients are more likely to repeat a desired behavior again in the hopes of receiving more positive feedback.

There are several types of behavioral modification therapy still used today, particularly to help those with anxieties, phobias, negative habits, or similar conditions and disorders. In addition, the concepts of behavioral modification may be used to help patients change behaviors to prevent disease or decrease the likelihood of a serious health crisis. In these cases however, the motivation for changing behavior lies in promises of a healthier future, rather than an immediate reward or punishment. Taking insulin after a diabetes diagnosis to prevent a diabetic crisis and increase one's lifespan would be one example. Changing one's diet to incorporate more fruits and vegetables and eliminate high fat foods after a heart attack is another example.

Assertiveness training: A 2004 article by Mouttapa examined the behavior of adolescent bullies, victims, and children who were both bullies and the subject of bullying (called aggressive victims). The study found that children who engaged in bullying were less likely to be perceived as victims of bullying themselves. The authors suggest that assertiveness training may help victims fight the aggression that occurs in bullying.

Aversion therapy: A 2004 Cochrane systemic review by Hajek et al. evaluated the efficacy of aversion therapy by pairing the act of smoking with an unpleasant stimulus. The reviewers concluded that the studies provide insufficient evidence to determine the efficacy of this form of aversion therapy.

Biofeedback: A 2007 study by Babu et al. evaluated the efficacy of electromyography biofeedback to reduce pain in patients with fibromyalgia syndrome. The authors found that the treatment with biofeedback therapy successfully reduced pain in the patient group.

Cognitive behavioral therapy (CBT): Labrecque et al. conducted a small study to evaluate the efficacy of cognitive behavioral therapy for comorbid panic disorder with agoraphobia and generalized anxiety disorder. After treatment, two out of the three study participants demonstrated high functioning, which was also demonstrated in the 12-month follow-up.

Dialectical behavior therapy (DBT): Goldstein et al. evaluated the efficacy of dialectical behavior therapy in reducing certain maladaptive behaviors in adolescents receiving treatment at an outpatient pediatric bipolar clinic. At the conclusion of the trial, the patients showed improvements in emotional dysregulation, depressive symptoms, suicidal behavior, and non-suicidal self-injurious behavior.

Exposure therapy: Rothbaum et al. compared the efficacy of virtual-reality and reality based exposure therapy in treating patients with a fear of flying. At follow-up, more than 70% of participants from both groups continued flying after the two different treatments.

Hypnosis: Various parts of the brain and spinal cord have been proposed as important in the potential pain-relieving properties of hypnotherapy. It has been suggested that the release of endogenous opioid peptides may play a role although preliminary evidence suggests that endorphins (brain chemicals involved in experiences of pleasure) may not be involved in the mechanism of action. Hypnosis is associated with a deep state of relaxation. Whether this represents a specific altered state of consciousness is the subject of continuing scientific debate. There are reports that suggestion alone, without the process of hypnosis, may achieve many of the same results of hypnosis although research in this area is not conclusive. It is not known why some individuals are more susceptible to hypnotic suggestion than others.

Systematic desensitization: A 2007 article by Coldwell evaluated the use of systematic desensitization in combination with placebo or a dose of alprazolam in patients with dental injection phobia. Dental fear was equally reduced in similar amounts in both groups one year after the study.

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Babu AS, Mathew E, Danda D, et al. Management of patients with fibromyalgia using biofeedback: A randomized control trial. Indian J Med Sci. 2007 Aug;61(8):455-61.

Coldwell SE, Wilhelm FH, Milgrom P, et al. Combining alprazolam with systematic desensitization therapy for dental injection phobia. J Anxiety Disord. 2007 Jan 23; Epub ahead of print.

Goldstein TR, Axelson DA, Birmaher B, et al. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):820-30.

Hajek P, Stead LF. Aversive smoking for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000546.

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Each type of behavior therapy has its own distinct approach and strives to attain a specific goal. In general, unwanted behaviors are changed through rewards, reinforcements, and desensitization.

Behavioral modification may be self-implemented or may be practiced under the supervision of a qualified health professional. Schools, hospitals, and psychiatric facilities may offer behavioral modification therapies.

Sessions are typically conducted with one individual patient but may also be done in groups. Sessions may occur as frequently as every week or may be more spread out in frequency.

Behavioral therapy often involves the cooperation of others, especially family and close friends, to reinforce desired behaviors.

Assertiveness training: Assertiveness training is a psychotherapy method that reinforces a person for stating negative and positive feelings directly. Assertiveness is considered the remedy for unnecessary fear, shyness, passivity, and/or anger. There is a wide range of situations in which this training may be appropriate. Individuals may be trained to speak up; make requests; ask for favors; express negative emotions (such as complaints, resentment, criticism, disagreement, intimidation, and the desire to be left alone); refuse requests; show positive emotions (such as joy, pride, liking someone, and attraction); give compliments; accept compliments with "thank you"; ask "why?" and question authority or tradition; initiate, carry on, change and terminate conversations comfortably; share feelings, opinions, and experiences with others; and deal with minor irritations before anger builds into intense resentment and explosive aggression.

Aversion therapy: Aversion therapy is a type of behavioral therapy that discourages pleasurable but destructive habits, such as smoking or excessive drinking, by associating them with unpleasant experiences. The patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning supposedly causes the patient to associate the stimulus with unpleasant sensations. For instance, a person may place unpleasant-tasting chemicals on the nails to discourage nail chewing, or an alcoholic may take prescription drugs that render the intake of alcohol unpleasant. Some forms of aversion therapy are considered harmless; however, controversial versions of this therapy have been used in the past and are generally not accepted today because of the potential for emotional trauma.

Biofeedback: Biofeedback is a technique used for helping an individual become conscious of otherwise unconscious bodily processes, so that the individual can gain some control over these processes and learn to manage the effects of various disorders (such as acute back pain or migraines). Proponents believe that biofeedback uses the mind to control the body. Biofeedback involves measuring a subject's bodily processes such as blood pressure, heart rate, skin temperature, galvanic skin response (sweating), and muscle tension and conveying such information to the individual in real-time in order to raise his or her awareness and conscious control of the related physiological activities. Interest in biofeedback has fluctuated since its origin in the 1960s. Today, biofeedback is increasing in popularity again perhaps because of the general increase of interest in complementary and alternative medicine modalities.

Cognitive therapy: In cognitive therapy treatments, the physician talks to a patient about their negative thoughts and how to replace them with positive thoughts, which may help stop the overall pattern of negative thought formation. Patients may talk about any problems they have been having, how they have been feeling, and their goals for therapy. The physician and patient agree upon the frequency of sessions. Visits may be weekly, monthly, or occur at other intervals. Patients may learn new ways to think about situations disturbing them and how to cope with feelings such as anger, anxiety, shyness, or panic. Cognitive therapy is designed to help identify and correct distorted thought (cognitive) patterns that can lead to feelings and behaviors that are troublesome, self-defeating, or self-destructive. Cognitive therapy is based on the premise that how an individual interprets experiences determines the way the individual feels and behaves. Like behavioral therapy, cognitive therapy focuses on current problems to alleviate symptoms, rather than addressing underlying or past conflicts. However, unlike behavioral therapy, , experiences outside of the therapy session are an important part of the cognitive therapy process. The patient consciously attempts to apply the skills and techniques discussed with the therapist in other areas of their lives.

Cognitive behavioral therapy (CBT): Cognitive behavioral therapy focuses on patterns of thinking that are counterproductive and the beliefs that underlie such thinking. For example, a person who is depressed may have the belief, "I'm worthless," and a person with a phobia may have the belief, "I am in danger." The individual is encouraged to view such beliefs as hypotheses (an interpretation of how events may unfold), rather than facts (an inevitability that events will unfold in a particular way) and to test out such beliefs by running experiments (putting one's self into a particular situation to see if one's hypothesis is actually true all of the time). Individuals are encouraged to monitor and record thoughts that arise automatically to determine patterns of biases in thinking and to develop more adaptive (functional) alternatives to their thoughts. CBT therapists are often active, problem-focused and goal-directed.

Studies of CBT have demonstrated its potential usefulness for a wide variety of disorders including but not limited to mood, anxiety, personality, eating, substance abuse, and psychotic disorders. Some studies have suggested that CBT may be as useful as antidepressant medication for individuals with depression and may be superior to antidepressants in preventing relapse. Patients receiving CBT for depression are encouraged to schedule enjoyable activities in order to increase the amount of pleasure they experience. Depressed patients learn how to restructure negative thought patterns in order to interpret their environment in a less biased way. CBT for bipolar disorder is used in addition to medication and focuses on education about the disorder and understanding cues and triggers for relapse. Studies indicate that bipolar patients who receive CBT in addition to treatment with medication have better outcomes than patients who do not receive CBT.

CBT is also used to treat anxiety disorders. Patients who experience persistent panic attacks are encouraged to test out beliefs they have related to such attacks, such as specific fears related to bodily sensations, and to develop realistic responses to such beliefs. Patients who experience obsessions and compulsions are guided to expose themselves to what they fear (usually what will happen if they do not perform the compulsion that they obsess about), thus allowing the beliefs surrounding their fears to be identified and modified.

During the past decade, CBT for schizophrenia has received considerable attention in the United Kingdom (UK). While this treatment continues to be in its infancy in the United States, studies in the UK have stimulated considerable interest in therapists in the United States where the therapy is becoming more prevalent. Treatment focuses on thought patterns that cause distress and also on the development of more adaptive realistic interpretations of events. Delusions are treated by developing an understanding of the kind of evidence the person uses to support their beliefs and encouraging the patient to recognize evidence that may have been overlooked and that does not support these beliefs. The assumed power of "voices" is tested, and patients are encouraged to utilize various coping mechanisms to test the controllability of auditory hallucinations.

CBT trained professionals may include psychologists, psychiatrists, social workers, and psychiatric nurses. Individuals seeking treatment using a CBT approach are encouraged to ask their therapist what CBT training they have had or to contact a Center for Cognitive Therapy and request a referral in their geographical location.

Creative art therapy: Creative art therapy uses the creative process to help individuals who might have difficulty expressing their thoughts and feelings. Creative arts may help a person increase self-awareness, cope with symptoms and traumatic experiences, and/or cultivate positive changes. Creative art therapy, also known as expressional therapy, includes activities such as art, dance and movement, drama, music, and poetry. It is thought that by expressing their feelings, experiences, and thoughts in a creative way, patients may work through difficulties they experience or become more ready to discuss their emotional states.

Dialectical behavior therapy (DBT): The primary objective of dialectical behavior therapy is to teach behavioral skills to help an individual tolerate stress, regulate emotions, and improve relationships with others. It was designed for people with borderline personality disorder who often have suicidal behavior and has also been adapted for other conditions including eating disorders or substance abuse. Dialectical behavior therapy originates partially from a philosophical process called dialectics, in which seemingly contradictory facts or ideas are weighed against each other to come up with a resolution or balance. Individuals with an eating disorder who fear they will not be loved unless a certain amount of weight is lost may be encouraged to examine the people in their life who care about them. A person with borderline personality disorder may learn to sit with difficult emotions. A suicidal person may learn other ways to deal with stress other than ending their own life.

Exposure therapy: Exposure therapy is a form of behavior therapy that deliberately exposes a person to the very thing that he/she finds upsetting or disturbing. It may be particularly useful for people with obsessive-compulsive disorder (OCD) or posttraumatic stress disorder (PTSD). It is believed that under controlled circumstances, exposure to the event or things that trigger obsessive thoughts or traumatic reactions may help a person learn to cope with them by working through the trauma. This method is considered controversial and should only be considered under the direction of a trained healthcare provider.

Flooding: Flooding involves forcing an individual to face an object or situation that causes anxiety or brings up difficult emotions. This form of therapy is used for a variety of conditions. Anxiety producers are presented in intense forms, either in imagination or in an individual's actual life. The presentations, which act as desensitizers, are continued until the stimuli no longer produce disabling anxiety. This therapy is considered controversial and thought by many to be unethical because of potential to cause trauma.

Hypnosis: The term hypnosis is derived from the Greek word hypnos, meaning sleep. The origin of modern Western hypnotherapy is often traced to the Austrian physician Franz Anton Mesmer who believed that illness is caused by an imbalance of magnetic fluids in the body that can be corrected through "animal magnetism." He asserted that the hypnotist's own personal magnetism can be transferred to a patient. In the mid 20th Century, the British and American Medical Associations and the American Psychological Association endorsed hypnosis as a medical procedure.

The process of hypnotherapy can be divided into pre-suggestion, suggestion, and post-suggestion phases. The pre-suggestion component may include selective attention focusing with distraction, imagery, and relaxation methods. An aim is to reach an altered state of consciousness in which the conscious mind is relaxed, the unconscious mind is more accessible, and the subject is susceptible to suggestion. In the suggestion phase, specific goals or impressions are presented, questions may be asked of the subject, or memories may be explored. The post-suggestion phase occurs after a return to a normal state of consciousness, and new behaviors based on hypnotic suggestions may be practiced.

It has been suggested that there is a risk of false memories (confabulation) as a result of some types of hypnotherapy although scientific research is limited in this area. The degree of susceptibility to hypnosis and suggestion appears to vary between individuals, with some individuals being particularly more open to suggestion than others. Some practitioners believe that a client's ability to be hypnotized can be increased if he or she becomes more open to the process.

The therapeutic goals of hypnotherapy vary and may include the treatment of psychological or medical conditions or alteration of behaviors, habits, or emotions. Self-hypnosis techniques may be used as an adjunct to sessions with a hypnotherapist.

The mechanism of action of hypnosis is not well understood. Some physiological changes have been associated with hypnosis, including alterations in skin or body temperature, heart rate, blood pressure, brain wave patterns (alpha waves), intestinal secretions, and immune responses. Similar changes have been reported with other forms of relaxation. Some scientists suggest that neuroendocrine pathways, such as the hypothalamic-pituitary-adrenal axis or the limbic system (emotional center of the brain), are central to connecting bodily functions with the mind, memory, and emotions. Hypnosis is theorized to activate these pathways. Various parts of the brain and spinal cord have been proposed as important in the pain-relieving properties of hypnotherapy. It has been suggested that the release of endogenous opioid peptides may play a role as pain receptor modulators. Preliminary evidence suggests that endorphins, which suppress pain reception, may not be involved in the mechanism of action.

Hypnosis is associated with a deep state of relaxation. Whether this represents a specific altered state of consciousness is the subject of continuing scientific debate. There are reports that suggestion alone, without the process of hypnosis, can achieve many of the same results although research in this area is not conclusive. It is not known why some individuals are more susceptible to hypnotic suggestion than others.

There is wide variation in the training and credentials of hypnotherapists. Certification is granted by multiple organizations with different requirements. In the United States, there is no universally accepted standard or licensing for hypnotherapists. Although many therapists are not licensed medical professionals, some doctors, dentists, and psychologists are trained in hypnotherapy and may use hypnosis in their practices. Books and audiotapes are available for training in self-hypnosis although these have not been well evaluated scientifically.

Hypnosis may be used as an adjunct to other techniques, such as cognitive behavioral psychotherapy. The length of hypnosis sessions may vary from a single brief encounter to regularly scheduled longer appointments. Group sessions may also be offered.

Punishment: In punishment therapy, positive punishment occurs when a behavior is followed by an unpleasant stimulus resulting in a decrease in that behavior. Negative punishment occurs when a behavior is followed by the removal of a pleasant stimulus, such as taking away a child's toy, resulting in a decrease in that behavior. A type of learning in which a certain behavior (usually negative) is not done in an attempt to not receive a punishment is termed avoidance learning. Extinction occurs when a behavior that had previously been reinforced no longer occurs.

Reinforcement: In reinforcement therapy, reinforcement is a consequence that causes a behavior to occur with greater frequency. In contrast, a punishment is a consequence that causes a behavior to occur with less frequency. According to Skinner's theory of operant conditioning, the two methods of decreasing a behavior or response are punishment or extinction. Positive reinforcement occurs when a behavior (response) is followed by a pleasant stimulus that increases that behavior. Negative reinforcement occurs when a behavior is followed by the removal of an unpleasant stimulus increasing that behavior.

Systematic desensitization: Systematic desensitization is a type of behavioral therapy used to overcome phobias and other anxiety disorders. More specifically, it is a type of Pavlovian therapy developed by the South African psychiatrist, Joseph Wolpe. Systematic desensitization is sometimes called graduated exposure therapy.

To begin the process of systematic desensitization, one must first be taught relaxation skills in order to control fear and anxiety responses to specific phobias. Once the individual has been taught these skills, he or she must use them to react towards and overcome situations in an established hierarchy of fears. It is believed that an individual will learn to cope and overcome the fear in each step of the hierarchy, which will lead to overcoming the last step of the fear in the hierarchy.

Specific phobias are one class of mental illness often treated through systematic desensitization. The therapist might encourage subjects to examine what they imagine happening when exposed to the phobic object, which allows them to recognize their catastrophic visions and contrast them with the actual outcome. For example, patients with snake phobias might imagine any snake they encounter coiling itself around their neck and strangling them. Research has demonstrated the potential effectiveness of systematic desensitization in helping subjects reduce similar animal phobias.

The second component of systematic desensitization is gradual exposure to the feared object. The therapist would begin by asking the patient to develop a fear hierarchy, listing the relative unpleasantness of various types of exposure. For example, seeing a picture of a snake in a newspaper might be rated 5 of 100 while having several live snakes crawling on one's neck would be the most fearful experience possible. Once the patient has practiced their relaxation technique, the therapist would then present them with the photograph and help them relax. They would then present increasingly unpleasant situations such as a poster of a snake, a small snake in a box in the other room, a snake in a clear box in view, and then touching the snake. At each step in the progression, the patient is thought to be desensitized to the phobia through the use of the coping technique. It is believed that when the patient realizes that nothing harmful happens to them as a result of the object or situation previously feared, and then the fear gradually extinguishes.

Changing health related behaviors: The use of behavior modification to alter health-related behavior is not as direct as behavior modification to change psychological behavior. This is because the potential benefits of changing health-related behavior are not as immediate as emotional modifications. For instance, a person undergoing assertiveness training may experience immediate feelings of empowerment after gathering the courage to voice their opinion. However, a person who wants to for example avoid a heart attack must imagine the potentially devastating impact of cardiovascular problems a year and perhaps, even decades into the future. Many people find changing health related behaviors difficult because the stimulus response (for example, to avoid having a heart attack, experiencing disability from a heart attack, or possibly facing death due to a heart attack) might occur many years or even decades later.